This two page document is a registration and agreement form for participants of the Elev8 event hosted by the Southwest Region NYI from May 24-27, 2013 at Point Loma Nazarene University. It requests emergency contact and medical information. The participant and their parent/guardian must sign agreeing to accept the risks of participation, release the NYI from liability, follow event rules, and confirm they have medical insurance.

1. Both sides/pages of this form must be completed and turned in at event check-in prior to participation
SOUTHWEST
REGION
NYI
ELEV8
-­‐
May
24-­‐27,
2013
Point
Loma
Nazarene
University
San
Diego,
California
Participant
Registration
Agreement
Form
PARTICIPANT INFORMATION EMERGENCY CONTACT 1 INFORMATION
Participant Name:______________________________________ Name: _________________________________________________
Date of Birth: _________________________ Age::___________ Relationship to Participant _________________________________
Street Address:: ________________________________________ Phone Number: __________________________________________
City, State, Zip _________________________________________ EMERGENCY CONTACT 2 INFORMATION
Cell Phone: ___________________________________________ Name: _________________________________________________
Church:: _____________________________________________ Relationship to Participant:_________________________________
District: ______________________________________________ Phone Number: __________________________________________
MEDICAL INFORMATION
Physician Name: ______________________________________ Phone: _________________________________________________
Health Ins. Co: ________________________________________ Insurance ID #: __________________________________________
Please describe below any health (medical, physical, psychological, emotional) conditions, special circumstances, medications, or
Allergies that our event staff should be aware of:
Elev8 Participation Agreement Form
Updated 2/28/13

2. Both sides/pages of this form must be completed and turned in at event check-in prior to participation
PARTICIPANT AGREEMENT
I, _________________________________, of _____________________, ____________________, ___________ am the ( ) father, ( ) mother,
(name of parent or guardian) (city) (county) (state)
( ) legal guardian (check one) of ________________________________ a minor of whom I have full custody and control, who will be attending the
(name of minor)
Southwest Region’s Elev8 on the campus of Point Loma Nazarene University, City of San Diego, County of San Diego, State of California.
I, _________________________________ hereby acknowledge that I have voluntarily decided to participate in the above detailed Trip/Event.
(name of participant)
INFORMED CONSENT: I have been informed and am confident that I understand the various aspects of this Trip/Event including but not limited to
the arrangements for finances, travel, itinerary and logistics. I further understand and acknowledge that despite careful planning and supervision,
serious injuries might occur during this Trip/Event. Persons involved may sustain fatal or serious injury, property damage, or severe social and/or
economic loss as a consequence of not only their own actions, inactions, or negligence, but the actions, inactions, or negligence of others, weather
conditions, conditions of equipment, language barriers, differing social cultures and laws. There may also be other risks not foreseeable at this time.
ACCEPTANCE OF RISK AND RELEASE OF LIABILITY: I accept full responsibility for the foregoing risk of injury, permanent disability or death. In
consideration of the opportunity to participate in this Trip/Event I release and discharge the Southwest Region Nazarene Youth International, its
officers, employees, and agents (hereinafter collectively referred to as “SWR-NYI”) from all liability defined herein arising out of or in connection with
my participation in the above described Trip/Event. For the purpose of this Agreement, liability means all claims, demands, causes of action, suits or
judgments of any kind (including court costs and attorney’s fees) that I, my heirs, executors, administrators, assignees, or any other person or entity
may have against the SWR-NYI because of my death, personal injury, illness, or for any loss. I hereby agree that this Agreement shall be
constructed in accordance with the laws of the State of California.
INDEMNIFICATION: I agree not to sue the SWR-NYI and hold harmless, defend, and indemnify the SWR-NYI from any and all liability as described
above that may occur due to my participation.
PARTICIPANT AGREEMENT: I hereby approve this application and certify its correctness.
Rules and Requirements: I understand that all students attending will be expected to act in a Christ-like manner. I acknowledge that I
am responsible for my own actions and cannot expect twenty-four hour supervision by a SWR-NYI or any Trip/Event official. I further grant
the righto the SWR-NYI or any Trip/Event official to terminate my participation in the Trip/Event if it is determined that my conduct is
detrimental to the best interest of the group. This includes, but not limited to the disruptions of meetings, or scheduled events and can
result in the disciplinary action of the SWR-NYI Staff, up to and including expulsion. Parents will be responsible to transport their
son/daughter home immediately upon notification and the costs shall be at their own expense. I hereby understand and agree to the
above rules and requirements.
Medical Insurance: I hereby confirm I am covered by medical insurance that will pay for medical services required and/or received for the
period of the travel.
Medical Consent: In the event of any medical emergency, I authorize and consent to any x-ray examination, anesthetic, medical, dental,
or surgical diagnosis or treatment and/or hospital care deemed necessary for my safety and protection.
I HAVE READ THIS AGREEMENT AND RELEASE ALL LIABILITY AND UNDERSTAND THE TERMS. I EXECUTE THIS
AGREEMENT VOLUNTARILY WITH FULL KNOWLDEDGE OF ITS SIGNIFICANCE.
_____________________________________ _____________________________________
Printed Name of Parent/Guardian Printed Name of Participant
_____________________________________ _____________________________________
Signature of Parent/Guardian Signature of Participant
___________________ ____________________
Date Date